Preoperative Factors Predict Postoperative Trajectories of Pain and Disability Following Surgery for Degenerative Lumbar Spinal Stenosis.

STUDY DESIGN: Longitudinal analysis of prospectively collected data. OBJECTIVE: Investigate potential predictors of poor outcome following surgery for degenerative lumbar spinal stenosis (LSS). SUMMARY OF BACKGROUND DATA: LSS is the most common reason for an older person to undergo spinal surgery, yet little information is available to inform patient selection. METHODS: We recruited LSS surgical candidates from 13 orthopedic and neurological surgery centers. Potential outcome predictors included demographic, health, clinical, and surgery-related variables. Outcome measures were leg and back numeric pain rating scales and Oswestry disability index scores obtained before surgery and after 3, 12, and 24 postoperative months. We classified surgical outcomes based on trajectories of leg pain and a composite measure of overall outcome (leg pain, back pain, and disability). RESULTS: Data from 529 patients (mean [SD] age = 66.5 [9.1] yrs; 46% female) were included. In total, 36.1% and 27.6% of patients were classified as experiencing a poor leg pain outcome and overall outcome, respectively. For both outcomes, patients receiving compensation or with depression/depression risk were more likely, and patients participating in regular exercise were less likely to have poor outcomes. Lower health-related quality of life, previous spine surgery, and preoperative anticonvulsant medication use were associated with poor leg pain outcome. Patients with ASA scores more than two, greater preoperative disability, and longer pain duration or surgical waits were more likely to have a poor overall outcome. Patients who received preoperative chiropractic or physiotherapy treatment were less likely to report a poor overall outcome. Multivariable models demonstrated poor-to acceptable (leg pain) and excellent (overall outcome) discrimination. CONCLUSION: Approximately one in three patients with LSS experience a poor clinical outcome consistent with surgical non-response. Demographic, health, and clinical factors were more predictive of clinical outcome than surgery-related factors. These predictors may assist surgeons with patient selection and inform shared decision-making for patients with symptomatic LSS. LEVEL OF EVIDENCE: 2.

Effect of Perioperative Vitamin C Supplementation on Postoperative Pain and the Incidence of Chronic Regional Pain Syndrome: A Systematic Review and Meta-Analysis.

OBJECTIVES: Postoperative pain can contribute to increased risk for complications and lengthened hospital stays. The objective was to analyze the effects of perioperative vitamin C supplementation on postoperative pain and the development of complex regional pain syndrome I (CRPS I) in patients undergoing surgical procedures. MATERIALS AND METHODS: A systematic review of published literature was performed through April 2014. References from relevant studies were scanned for additional studies. Results were screened for relevance independently, and full-text studies were assessed for eligibility. Reporting quality was assessed using a modified Newcastle-Ottawa Scale. RESULTS: The search strategy yielded 710 studies, of which 13 were included: 7 on postoperative pain and 6 on CRPS I. In the final analysis, 1 relevant study found a reduction in postoperative morphine utilization after preoperative vitamin C consumption, whereas another showed no difference in postoperative pain outcomes between the vitamin C and control groups. A meta-analysis of 3 applicable CRPS I studies showed a decrease in postoperative CRPS I after perioperative vitamin C supplementation (relative risk=2.25; τ²=0). DISCUSSION: There is moderate-level evidence supporting the use of a 2 g preoperative dose of vitamin C as an adjunct for reducing postoperative morphine consumption, and high-level evidence supporting perioperative vitamin C supplementation of 1 g/d for 50 days for CRPS I prevention after extremity surgery. Additional studies are necessary to increase the level of evidence to determine the overall effectiveness and optimum dosage of vitamin C.

Surgeon attitudes toward nonphysician screening of low back or low back-related leg pain patients referred for surgical assessment: a survey of Canadian spine surgeons.

STUDY DESIGN: Questionnaire survey. OBJECTIVE: To explore spine surgeons' attitudes toward the involvement of nonphysician clinicians (NPCs) to screen patients with low back or low back-related leg pain referred for surgical assessment. SUMMARY OF BACKGROUND DATA: Although the utilization of physician assistants is common in several healthcare systems, the attitude of spine surgeons toward the independent assessment of patients by NPCs remains uncertain. METHODS: We administered a 28-item survey to all 101 surgeon members of the Canadian Spine Society, which inquired about demographic variables, patient screening efficiency, typical wait times for both assessment and surgery, important components of low back-related complaints history and examination, indicators for assessment by a surgeon, and attitudes toward the use of NPCs to screen patients with low back and leg pain referred for elective surgical assessment. RESULTS: Eighty-five spine surgeons completed our survey, for a response rate of 84.1%. Most respondents (77.6%) were interested in working with an NPC to screen patients with low back-related complaints referred for elective surgical assessment. Perception of suboptimal wait time for consultation and poor screening efficiency for surgical candidates were associated with greater surgeon interest in an NPC model of care. We achieved majority consensus regarding the core components for a low back-related complaints history and examination, and findings that would support surgical assessment. A majority of respondents (75.3%) agreed that they would be comfortable not assessing patients with low back-related complaints referred to their practice if indications for surgery were ruled out by an NPC. CONCLUSION: The majority of Canadian spine surgeons were open to an NPC model of care to assess and triage nonurgent or emergent low back-related complaints. Clinical trials to establish the effectiveness and acceptance of an NPC model of care by all stakeholders are urgently needed.